Abstract : OBJECTIVE: Reports of large series of patients who had undergone successful cranial neurosurgery without hair removal led part of our team to abandon the practice of shaving patients' heads pre-operatively. The aim of this study was to assess whether this change in routine, which was implemented in 1992, has affected the rate of postoperative infection in our cranial surgery patients. METHODS: A group of patients whose heads were shaved pre-operatively was compared to a group whose hair was not shaved prior to cranial surgery. The latter patients had their hair washed with shampoo and 4% chlorhexidine within 24 hours of their operation. In the operating room, the surgical site was scrubbed for 8-10 minutes with 4% chlorhexidine diluted with water, and then cleansed with 10% povidone-iodine solution. Prophylactic antibiotics were administered for 3 days. RESULTS: We performed 1,038 cranial procedures without hair removal. The procedures included craniotomy for tumour, trauma, aneurysm, other vascular lesions and intracerebral haemorrhage (n = 847), stereotactic biopsy (n = 90), stereotactic craniotomy (n = 34), ventriculoperitoneal shunt placement (n = 27), surgical treatment of infection with aspiration of brain abscess or resection of infected tissue (n = 14), microvascular decompression for trigeminal neuralgia or hemifacial spasm (n = 11), and other miscellaneous procedures (n = 15). We observed 13 postoperative wound infections (1.25%), including 9 deep (0.87%) and 4 superficial infections (0.39%). There was no significant difference between the rate of infection in patients whose heads were shaven (12/980) and the rate in those whose hair was spared (13/1038) (p > 0.05). In addition. there were no other problems related to the surgical preparation technique in the latter group. CONCLUSION: Cranial surgery without hair removal is safe and does not increase the risk of surgical wound infection. Patients naturally prefer to keep their full head of hair. We believe that preoperative hair removal is not necessary in preparation for any type of cranial neurosurgery.

Abstract: STUDY OBJECTIVE: Irrigation, a critical component of wound management, is commonly performed with sterile normal saline solution. The purpose of this study was to compare the infection rates of wounds irrigated with normal saline solution versus those of wounds irrigated with running tap water. METHODS: A prospective trial was conducted in an urban pediatric emergency department. Tap water pressure and flow rates were measured, and cultures were obtained before the study and at 5 months after study initiation. Patients 1 to 17 years of age presenting to the pediatric ED with a simple laceration were eligible. Exclusion criteria included immunocompromise, complicated lacerations, or current use of or need for antibiotics. Patients were allocated to the running tap water group or the standard normal saline solution irrigation group. Wounds were closed in standard fashion. Patients returned to the pediatric ED in 48 to 72 hours for evaluation. RESULTS: Two hundred seventy-one patients were enrolled in the normal saline solution group and 259 in the tap water group. Tap water and normal saline solution pressures and flow rates differed. The groups did not differ in terms of patient demographic characteristics or wound characteristics. However, more wounds were located on the hand in the tap water group (21.3%; 95% confidence interval [CI] 16.3% to 27.1%) compared with those in the normal saline solution group (9.2%; 95% CI 5.9% to 13.4%). The wound infection rates were similar in the 2 groups (normal saline solution group: 2.8% [95% CI 1.1% to 5.7%] versus running tap water group: 2.9% [95% CI 1.2% to 5.9%]). CONCLUSION: There were no clinically important differences in infection rates between wounds irrigated with tap water or normal saline solution. Tap water might be an effective alternative to normal saline solution for wound irrigation in children.

Abstract: BACKGROUND: Various solutions have been recommended for cleansing wounds, however normal saline is favoured as it is an isotonic solution and does not interfere with the normal healing process. Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost effective, however, there is an unresolved debate about its use.
OBJECTIVES: The objective of this review was to assess the effects of water compared to other solutions for wound cleansing. SEARCH STRATEGY: Randomised and quasi-randomised controlled trials were identified by electronic searches of Cochrane Wounds Group Specialised Trials Register, MEDLINE, EMBASE, CINAHL, and the Cochrane Controlled Trials Register. Primary authors, company representatives and content experts were contacted to identify eligible studies. Reference lists from included trials were also searched. SELECTION CRITERIA: Randomised and quasi randomised controlled trials that compared the use of water with other solutions for wound cleansing were eligible for inclusion. Additional criteria were outcomes that included objective or subjective measures of wound infection or healing. DATA COLLECTION AND ANALYSIS: Trial selection, data extraction and quality assessment were carried out independently by two reviewers and checked by a third reviewer. Differences in opinion were settled by discussion. Some data were pooled using a random effects model. MAIN RESULTS: Three trials were identified that compared rates of infection and healing in wounds cleansed with water and normal saline, two compared cleansing with no cleansing and one compared procaine spirit with water. There were no standard criteria for the assessment of wound infection across the trials which limited the ability to pool the data. The major comparisons were water vs normal saline, and tap water vs no cleansing. For chronic wounds, the odds of developing an infection when cleansed with tap water compared with normal saline was 0.16, 95 % Confidence Interval (CI) 0.01, 2.96. Use of tap water to cleanse acute wounds was associated with a lower rate of infection than saline (OR 0.52, 95 % CI 0.28, 0.96). No statistically significant differences in infection rates were seen when wounds were cleansed with tap water or not cleansed at all (OR 1.06, 95 % CI 0.06, 17.47). Similarly there was no difference in the infection rate in wounds cleansed with water or procaine spirit and those cleansed with isotonic saline, distilled water and boiled water (OR 0.55, 95 % CI 0.18,1.62). REVIEWER'S CONCLUSIONS: Although the evidence is limited one trial has suggested that the use of tap water to cleanse acute wounds reduces the infection rate and other trials conclude that there is no difference in the infection and healing rates between wounds that were not cleansed and those cleansed with tap water and other solutions. However the quality of the tap water should be considered prior to its use and in the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents.

Can tap water be used to irrigate wounds in A&E?

Author : O'Neill D.

Magazine : Nurs Times 2002 Apr 2-8;98(14):56-9

Abstract : After critiquing the seven selected articles, it seems likely that tap water can be used as an irrigant and cleansing agent for soft-tissue wounds. However, the current research on tap water has involved human and rat wound studies and tap water culture studies (Dire, 1990; Riyat and Quinton, 1997; Moscati, 1998). The research is strong, but limitations in current research remain an issue for practice (Towler, 2000). The use of tap water is a cost and practicality issue, and changing current practice is always difficult, as it would seem that the use normal saline is more of a ritualistic process rather than one based on hard evidence (Glover, 1999). Two key conclusions could be drawn from the available research: The tap water tested was generally agreed to be safe from harmful bacteria and had no contaminating bacteria; Human and rat models showed a clear benefit in using tap water to cleanse soft tissue wounds, thus concluding tap water is safe for use on wounds (Towler, 2000). The financial benefits were also stated in the studies; tap water can have huge cost-saving potential for A&E departments. In an increasingly cost-conscious NHS this could be a major driving factor for changing practice. However, there were limitations in the methodologies of the selected articles in this critique. Most of the studies measured wound infection rates, but the various researchers did not take into account other factors affecting the likelihood of infection rates and wound progress which would ultimately affect wound infection rates by killing any bacteria in vivo.

Evidence-based practice: tap water cleansing of leg ulcers in the community.

Author : Selim P, Bashford C, Grossman C.

Magazine : J Clin Nurs. 2001 May;10(3):372-9.

Abstract : To establish and encourage wound management practices based on evidence, a Community Nursing Organization in metropolitan Adelaide began a series of research initiatives in 1997. Based on the results of a wound management survey, and through the processes of participatory action research with clinicians, many wound management practice changes were instigated throughout the Community Nursing Organization. One question remains unanswered: What is the evidence for the use of sterile saline or clean tap water for cleansing of leg ulcers in the community? In this paper we describe a project where we applied the three principles of planning, action and evaluation. Application of these principles enabled clinicians to collaborate in the search for evidence to support or refute tap water cleansing of leg ulcers. To conclude, we report on a pilot research project undertaken to obtain further evidence either to support or refute the use of tap water cleansing for leg ulcers in the community.

Wound irrigation with tap water.

Author : Moscati RM, Reardon RF, Lerner EB, Mayrose J.

Magazine : Acad Emerg Med 1998 Nov;5(11):1076-80

Abstract : OBJECTIVE: The study hypothesis was that irrigation with tap water is as efficacious as irrigation with sterile saline in removing bacteria from simple lacerations in preparation for wound closure. METHODS: The study was conducted in a laboratory rat model previously described in the literature for evaluating wound irrigation techniques. The study used a randomized, blinded crossover design using 10 animals. Two full-thickness skin lacerations were made on each animal and each wound was inoculated with standardized concentrations of a Staphylococcus aureus broth. Wounds were irrigated for 4 minutes with normal saline from a syringe or 4 minutes with tap water from a faucet. Tissue specimens were sampled from each laceration prior to and following irrigation. Bacterial counts per gram of tissue were determined for each specimen and compared pre- and postirrigation. RESULTS: Preirrigation bacterial counts were not significantly different for saline vs tap water specimens. The wounds irrigated with saline had a mean reduction in bacterial count of 54.7% (SD=+/-28%), while the wounds irrigated with tap water had a mean reduction in bacterial count of 80.6% (SD=+/-20%) (p<0.05, 2-tailed, paired t-test). CONCLUSIONS: In this animal model, bacterial decontamination of simple lacerations was not compromised, and was actually improved using tap water irrigation. This is most likely due to the mechanical differences in the types of irrigation. In certain instances, such as with upper-extremity lacerations, tap water irrigation would likely be cheaper and less labor-intensive than irrigation with normal saline from a syringe.

Comparison of normal saline with tap water for wound irrigation.

Author : Moscati R, Mayrose J, Fincher L, Jehle D.

Magazine : Am J Emerg Med 1998 Jul;16(4):379-81

Abstract : This study compared irrigation with tap water versus saline for removing bacteria from simple skin lacerations. The study was conducted in an animal model with a randomized, nonblinded crossover design using 10 500-g laboratory rats. Two full-thickness skin lacerations were made on each animal and inoculated with standardized concentrations of Staphylococcus aureus broth. Tissue specimens were removed before and after irrigation with 250 cc of either normal saline from a sterile syringe or water from a faucet. Bacterial counts were determined for each specimen and compared before and after irrigation. There was a mean reduction in bacterial counts of 81.6% with saline and 65.3% with tap water (P = .34). One tap water specimen had markedly aberrant bacterial counts compared with others. Excluding this specimen, the mean reduction for tap water was 80.2%. In this model, reduction in bacterial contamination of simple lacerations was not different comparing tap water with normal saline as an irrigant.

Tap water as a wound cleansing agent in accident and emergency.

Author : Riyat MS, Quinton DN.

Magazine : J Accid Emerg Med 1997 May;14(3):165-6

Abstract : OBJECTIVE: To investigate the bacterial cleanliness of tap water in a large accident and emergency (A&E) department for its possible use in the cleansing and irrigation of open traumatic wounds. METHODS: Tap water samples were collected from different areas within the department and analysed on two separate occasions for coliforms, S aureus, clostridia, pseudomonas, and beta haemolytic streptococci. RESULTS: Pathogenic bacteria were not isolated from the tap water samples within the A&E department. CONCLUSIONS: Tap water of drinking quality can be used to irrigate open traumatic wounds.

Comparison between sterile saline and tap water for the cleaning of acute traumatic soft tissue wounds.

Author : Angeras MH, Brandberg A, Falk A, Seeman T.

Magazine : Eur J Surg 1992 Jun-Jul;158(6-7):347-50

Abstract : OBJECTIVE--To find out if there were any differences in infection rates if acute traumatic soft tissue wounds were cleaned with tap water instead of sterile saline. DESIGN--Randomised study. SETTING--Emergency department at one city hospital. SUBJECTS--705 consecutive patient with soft tissue wounds less than six hours old that did not penetrate a viscus, cavity, or joint and could be treated by primary suture. INTERVENTIONS--Randomly allocated to have the wound cleaned with either sterile saline or tap water in addition to debridement. MAIN OUTCOME MEASURE--Rate of wound infection, the presence of which was indicated by pus in the wound and prolonged healing. RESULTS--The infection rate in wounds cleaned with sterile saline was 10.3% compared with 5.4% in wounds cleaned with tap water (p less than 0.05). Infected wounds were significantly larger than uninfected ones (p less than 0.05) and more likely to be located on a lower extremity (p less than 0.05). There were no microbiological differences between the two groups, and no bacterial species grown from tap water was subsequently grown from an infected wound. CONCLUSION--Sterile saline should be replaced by tap water for the cleaning of acute traumatic superficial soft tissue wounds.

Abstract : Context Surgical site infections prolong hospital stays, are among the leading nosocomial causes of morbidity, and a source of excess medical costs. Clinical studies comparing the risk of nosocomial infection after different hand antisepsis protocols are scarce.Objective To compare the effectiveness of hand-cleansing protocols in preventing surgical site infections during routine surgical practice.Design Randomized equivalence trial.Setting Six surgical services from teaching and nonteaching hospitals in France.Patients A total of 4387 consecutive patients who underwent clean and clean-contaminated surgery between January 1, 2000, and May 1, 2001.Interventions Surgical services used 2 hand-cleansing methods alternately every other month: a hand-rubbing protocol with 75% aqueous alcoholic solution containing propanol-1, propanol-2, and mecetronium etilsulfate; and a hand-scrubbing protocol with antiseptic preparation containing 4% povidone iodine or 4% chlorhexidine gluconate.Main Outcome Measures Thirty-day surgical site infection rates were the primary end point; operating department teams' tolerance of and compliance with hand antisepsis were secondary end points.Results The 2 protocols were comparable in regard to surgical site infection risk factors. Surgical site infection rates were 55 of 2252 (2.44%) in the hand-rubbing protocol and 53 of 2135 (2.48%) in the hand-scrubbing protocol, for a difference of 0.04% (95% confidence interval, -0.88% to 0.96%). Based on subsets of personnel, compliance with the recommended duration of hand antisepsis was better in the hand-rubbing protocol of the study compared with the hand-scrubbing protocol (44% vs 28%, respectively; P = .008), as was tolerance, with less skin dryness and less skin irritation after aqueous solution use.Conclusions Hand-rubbing with aqueous alcoholic solution, preceded by a 1-minute nonantiseptic hand wash before each surgeon's first procedure of the day and before any other procedure if the hands were soiled, was as effective as traditional hand-scrubbing with antiseptic soap in preventing surgical site infections. The hand-rubbing protocol was better tolerated by the surgical teams and improved compliance with hygiene guidelines. Hand-rubbing with liquid aqueous alcoholic solution can thus be safely used as an alternative to traditional surgical hand-scrubbing.

Abstract:The haemostatic effect of two new materials has been compared with surgical gauze and oxidized cellulose using a standardized liver laceration in New Zealand White rabbits. Following excision of a 3 cm2 disc of tissue from the liver, 42 rabbits were randomized to the use of gauze swabs (n = 6), oxidized cellulose (Surgicel) (n = 12), porcine collagen (Medistat) (n = 12) or calcium alginate (Kaltostat) (n = 12) to control the resulting haemorrhage. Blood loss and time to haemostasis were accurately recorded. The absorbable materials were left in situ and animals killed between 2 weeks and 6 months later to examine speed of absorption and resulting adhesions. Calcium alginate stopped bleeding in less than 3 min in all animals compared with a mean (+/- s.e.m.) of 5.7 +/- 0.75 min for porcine collagen, 12.5 +/- 0.9 min for oxidized cellulose and greater than 15 min with gauze (P less than 0.001). Oxidized cellulose and calcium alginate reabsorbed within 3 months leaving a fibrous scar, but a vigorous foreign body reaction was seen with porcine collagen which caused intestinal obstruction in 5 out of 12 animals within 3 months.